<p> Objective: Under-reporting of surgical errors inhibits development of knowledge and strategies that can lead to lower error rates. Mandatory error reporting programs have proliferated among states as one means of reducing the incidence of errors. Evidence suggests that errors are under-reported. Little is known of the perceptions of states regarding the risk of under-reporting, their responses to it and the ways they use reported data to improve patient safety. A qualitative study was conducted to assess the perceptions of state managers regarding the risk of under-reporting and the role of enforcement, analysis and feedback in current and ideal error reporting programs. </p><p> Methods: 24 state medical error reporting programs were surveyed for characteristics and perceptions of surgical error reporting compliance. A key informant sample of 11 states explored perceptions of barriers and facilitators to reporting, and current and ideal strategies for enforcement and data use. Qualitative data were coded for themes and key findings. A plan for change responds to the conclusions. </p><p> Results: 52% of states had discovered surgical errors through means other than required reporting by health care institutions. 76% of states reported that it was impossible to know whether all required reports were made. Some managers did not have adequate resources to enforce reporting, analyze data or engage the health care industry to improve patient safety. State managers understood most of the same reasons given by the health care industry in the literature for failure to report, except lack of program usefulness and feedback. Most managers valued using error data analysis in collaboration with the health care industry to reduce the incidence of surgical errors, but only 37.5% of states use data this way. </p><p> Conclusion: Most state managers do not know whether their programs receive all required surgical error reports, and most do not have the resources to use data the way they would like to. Managers did not understand lack of program value and feedback as an important barrier. A plan for change provides education to states and recommendations that include standardization of reporting requirements, data sharing, and new requirements for error reporting.</p>

<p> Autism is a rapidly increasing global health concern. In the United States, many families and individuals with autism find it difficult to access treatment for this condition because it is commonly excluded from health insurance plans. Apprehension about passing autism health insurance legislation includes concerns regarding the impact on small businesses. Many businesses advocates and law makers have expressed concern that passing an autism health insurance mandate will cause small businesses to close or to stop offering health insurance plans to their employees. In an effort to substantiate these concerns, this study provides an analysis of publicly available data on small business closures and small business health insurance plans to determine if a relationship exists between passing an autism health insurance mandate and a change in the number of small business closures or the percentage of small businesses that offer health insurance plans to their employees.</p><p> The methodology for this study includes testing of Pearson&rsquo;s <i> r</i> correlation models, semipartial correlation models and analysis of variance (ANOVA) models. Findings indicate there is insufficient evidence to conclude that a relationship exists between enacting an autism health insurance mandate and an increase in the number of small business closures. In addition, findings indicate there is insufficient evidence to conclude that a relationship exists between enacting an autism health insurance mandate and a decrease in the percentage of small businesses offering health insurance to their employees. </p>

<p> This qualitative multi-site case study, situated in the context of Ukraine's post-Soviet political economy, examined how orphanage educators' expectations and beliefs about orphans' academic abilities and potential, curriculum, peer relationships, and education policy shaped orphans' post-secondary education decisions and trajectories. Examination of the educational experiences of orphans and children deprived of parental care shed light on socio-economic inequalities confronting these marginalized youth in and beyond state care. This dissertation is informed by critical theories of social and cultural reproduction that examine the relationship between schooling and socio-economic inequalities. I draw mainly on the concepts of the hidden curriculum and forms of capital (cultural, social, and economic). </p><p> Research conducted in Ukraine, primarily through quantitative surveys, tends to pathologize orphans and neglects to investigate how their secondary education experiences impact their trajectories post-institutionalization. This study, framed in qualitative methodology, was informed by observations of daily in- and out-of-classroom activities in two orphanages; in-depth, semi-structured interviews and focus groups with Grade 10 and 11 orphanage students, orphanage educators and administrators, and orphanage alumni; and document analysis. I focused on 81 orphanage youth and 41 educators as key participants embedded in the orphanage system. </p><p> My findings demonstrated that, despite some institutional changes, the ideologies, regimes, and cultures of Ukrainian orphanages still reflect the Soviet legacy of sequestered institutions providing substandard quality education. My examination of orphanage education revealed that many teachers, informed by genetic deficit ideology, communicated low expectations for student success and implemented an unchallenging curriculum characterized by watered-down teaching and learning materials, oversimplified assignments, canceled classes, and inflated grades. This study uncovered nuanced use of a hidden curriculum that ensured social reproduction and what I term a "transformative hidden curriculum" that fostered student success through art therapy, soft pedagogy, and hard caring. </p><p> Furthermore, this study shed light on factors that influenced orphans' complex post-secondary education decision-making processes, including peer pressure to attend vocational school; teacher-directed versus teacher-encouraged decisions; and informed, independent decisions largely thwarted by structural constraints. Lack of cultural and social capital significantly limited orphans' options and disenfranchised them in the labor market, thus perpetuating social reproduction in Ukrainian society.</p>

<p> There is an emerging consensus among public health practitioners and policymakers alike that, given the existence of shared risk factors, the treatment of food insecurity and obesity requires integrated research and policy action. Referred to as the <i>food systems approach</i>, this perspective applies an ecological public health model for the conceptualization of the shared food environments from which food insecurity and obesity stem, and identifies opportunities for intervention centered on the promotion of healthy and sustainable food systems. One such food systems-based intervention that has garnered significant support is the redemption of the Supplemental Nutrition Assistance Program (SNAP) benefits at farmers' markets. However, the vast majority of studies that have examined the implementation of SNAP at farmers' markets have been conducted within a single market and have been designed to measure program impact, rather than the contextual determinants of program adoption and success. This study operationalizes the food systems approach and ecological model in order to examine the relationship between the implementation of SNAP at farmers' markets and macro-level physical food environment characteristics. Results indicate that the prevalence of SNAP-authorized farmers' markets is positively related to food system characteristics relating to local food production and distribution. The findings of this study contribute to the legitimacy of the food system approach and its application of an ecological public health model in the identification, formulation, and implementation of interventions designed to combat food insecurity and obesity. When enriched by the science of food environment assessment and measurement, the ecological model employed by the food systems approach provides a suitable framework for the systematic analysis of the macro-environmental context in which food systems-based interventions are implemented.</p>

<p> <b>Purpose:</b> Empirical evidence on impact of CABG report cards on the quality of CABG surgery is patchy, mixed and mainly comes from uncontrolled and short term studies. CABG report cards are associated with a small decline in mortality after controlling for an overall declining trend. Whether report card publication has caused this decline is not known. </p><p> <b>Methods:</b> I use difference-in-differences and difference-in-differences-in-differences with fixed and random effects in OLS, Logistic, FGLS and GMM regression frameworks in a quasi-experiment set up in State-level and patient-level HCUP data with risk-adjustment to assess long term impact of CABG report cards on CABG mortality and provider market share and volume. This study uses counterfactuals, and multiple States as treatment and control States. </p><p> <b>Results:</b> CABG shows steadier and 17% steeper decline in in-hospital mortality rate when compared with other equally complex surgeries, and 30% steeper improvement when compared with pneumonectomy. There is a strong secular and statistically significant trend of decreasing CABG mortality. States with and without report cards were similar in terms of CABG mortality at baseline. We do not see long term impact of CABG report cards, State-mandated or voluntary, on CABG in-hospital mortality. Nevertheless, report cards have caused a gain in market share of 6% and 5% for low mortality hospitals and surgeons respectively in face of a secular trend of rising market share of average mortality hospitals and surgeons. CABG report card policy was also associated with decrease in hospital volume by 152 surgeries and decrease in surgeon volume by 14 surgeries a year over and above the secular trend of declining CABG volumes. </p><p> <b>Conclusions:</b> Concurrent Society of Thoracic Surgeons intiative and spillover of effects across States may explain why we do not see impact of CABG report cards in long term on improvements in quality of CABG surgery. National and regional system interventions with State CABG report cards appear to have created a perfect storm leading to a rising tide of CABG quality which has benefitted all States. It appears the report cards are associated with a change in today's culture of medicine biased in favor of interventions and procedures.</p>

<p> As the rates of breast cancer continue to increase, researchers and medical professionals struggle to give a definitive cause of the disease or find a cure. Unfortunately, it seems that the chance of having a cancer diagnosis within one's lifetime is only increasing. Since breast cancer is somewhat unpredictable, the medical field has taken the pathway of attempting to minimize the risk of mortality through regular screening mammograms. Even with multiple initiatives to increase mammogram utilization, multiple demographic factors such as race, income status, and insurance coverage continue to be underserved. The present study will focus on income status and insurance coverage as barriers to regular screening mammograms. It is hypothesized that those women with low-income status and no insurance coverage are less likely to receive regular screening mammograms than those women with higher income and some type of insurance. After completing a statistical analysis, both hypotheses were supported.</p>

Research on belief perseverance--the finding that people cling to initial beliefs to an unwarranted extent--has demonstrated that a belief persists to the extent that there are more explanations available to the believer to support the original belief than to support alternative beliefs. Thus, explanatory evidence that supports an alternative target belief may be more effective in changing prior beliefs than statistical evidence. In an experiment testing this hypothesis, subjects read explanatory (biological) information and/or statistical (epidemiological) information supporting the belief that Acquired Immune Deficiency Syndrome (AIDS) cannot be spread by casual contact. Subjects' beliefs on this issue were assessed before and after reading this information. Subjects also evaluated the evidence they read. Finally, the availability of explanations supporting the target belief was assessed. Results indicated that: (1) explanatory evidence produced significant belief change, whereas statistical evidence did not; (2) evaluations of evidence were biased in accord with subjects' initial beliefs; (3) information polarized attitudes, although attitudes changed in the appropriate direction; (4) final beliefs were more congruent with the target alternative belief after subjects read explanatory information than after they read statistical information. Evidence was mixed regarding whether explanatory evidence was less subject to evaluation bias and subsequent attitude polarization than statistical information. In addition, explanation availability mediated the effectiveness of information in determining final beliefs, and evaluations of the evidence mediated the effect of initial beliefs on attitude polarization. A motivational construct, attitudes toward gay men, was related to initial beliefs and belief change--those with negative attitudes had more inappropriate beliefs and displayed less change in beliefs than those with moderate attitudes. However, evaluations of evidence were better predicted by initial beliefs than by attitudes toward gay men. This study has clear implications for those attempting to change beliefs, including those responsible for AIDS education: explanatory evidence is more effective than statistical evidence in changing beliefs.

This thesis examines the process of welfare policy-making in Quebec with respect to single mothers and their children. Historically, traditional notions of the role of women in society and the distinction between "deserving" and "undeserving" poor have inhibited adequate social assistance for single mothers. Chapter 1 examines the 1937 Needy Mother's Assistance Act, the first state assistance program for single mothers in Quebec. Chapter 2 discusses the ideological basis for present-day welfare policy making. The liberal feminist commitment to gender neutrality and acceptance of the marketplace economic model have abetted recent attacks on the Motherwork norm in welfare policy and thus reinforced existing disadvantages of single mothers. Chapter 3 examines the Quebec welfare policy-making process embodied in the 1987 position paper Towards an Income Security Policy and subsequent parliamentary commission hearings. The Return to School Program for single parents, and other provisions, with their renewed emphasis on the marketplace and their attack on the Tender Years Presumption, left single mothers effectively worse off under the new Income Security Act.

<p> Recently, the Centers for Medicare and Medicaid Services (CMS) ranked all hospitals based on Medicare readmission rates for heart attacks, heart failure, and pneumonia. CMS offered subsidies to hospitals ranked in the 4th quartile to develop community support services to reduce the problem of potentially preventable readmissions (PPRs). CMS cited 4 of the 5 hospitals in Prince George's County in the 4th quartile. The purpose of this quantitative research study was to investigate the relationship between community support services and the reduction of PPRs in Prince George's County. The Evans and Stoddart field model of health and well-being guided this study with support from Bertalannffy's general systems theory. This study sought to relate community support services to PPRs in Prince George's County in contrast to other Maryland counties. To evaluate relationships between community support services and the reduction of PPAs, secondary data were provided by CMS in conjunction with the Robert Wood Johnson Foundation and the University of Wisconsin. The data included 26 behavioral community support factors from 53,229 Medicare paid claims in Maryland residents from July 1, 2008 to June 30, 2011. Lack of diabetes screening is a community support factor within quality of care. Using multiple regressions, there was a statistically significant relationship found between diabetic screenings and pneumonia readmission rate. The implication for social change is that reimbursement of key screening recommendations to CMS, local government, and hospitals in Prince George's County may reduce readmission rates, thereby positively affecting patients, improving community health, and decreasing health care costs in Prince George's County.</p>

<p>Ghana?s democracy has been hailed by scholars, practitioners, and the international community in recent years as a shining example in the West African subregion as a result of the country?s record of organizing successive elections with minimal or no violence. However, the evaluation of Ghana?s democracy has predominantly focused on the elections and disproportionately captures the views of the political elite; conspicuously missing is the perspective of the ordinary Ghanaian. This presents an incomplete picture of Ghana?s democracy, given the relevance of citizens? participation in democratic societies. To address this gap in knowledge, this qualitative case study explored the practice of democracy in Ghana under the fourth republic from the perspective of the citizenry. Data were collected through face-to-face interviews with purposefully sampled ordinary Ghanaian citizens (n = 15), observation, and documents review. The data were then subjected to thematic and content analysis to reveal themes, categories, and patterns. The results revealed that the participating Ghanaians had dichotomous views, opinions, and experiences of democracy. Their experiences and opinions of the electoral system were generally positive, while their experiences and opinions of governance in the intervening years were generally negative. The study?s results should inspire a paradigm shift in the responsiveness of government to citizens and how the government engages with citizens on policy formulation and implementation. This study?s results can encourage positive social change with respect to the manner in which democratic performance is evaluated in Ghana by scholars, practitioners, and the international community.